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How Much Evidence Is Enough?

February 11, 2011

If it doesn’t directly impact clinical care, is it still worth doing? That’s the question I was recently asked while speaking to a physician group.

(Before I go any further, let me say that I welcome having my beliefs questioned. It’s one of the benefits of being able to travel all around the country and interact with so many wonderful people. I have many opportunities to learn and to become better.)

Anyway, a physician in the room stated that he did not believe the patient satisfaction survey was of much value due to the fact that it does not impact clinical outcomes. He also felt that a patient could be very satisfied, yet not receive good clinical care.

Let me address the second comment first. I agree. It is possible for patients to rate their care high in a survey and still not receive great clinical care. This is where an organization’s values come in. I don’t know of any organization that feels good if patient satisfaction is high and quality is not.

The inverse is also true. Many times an organization’s clinical quality can be excellent but other issues can lead patients to feel they did not receive excellent clinical care.

My comment the other day to a group of physicians in an academic medical center was, “Let’s have the patient’s perception of care match the clinical quality you are providing.”

Now, let’s go back to the challenge that started this blog entry: My first attempt to link the survey to the issue of clinical care was to read the questions. How well was your pain managed? How well were your needs responded to? How well were your questions answered? How well were things explained to you? How well were your home care instructions explained? I explained that I feel each of these can impact clinical care.

The physician disagreed, stating that these issues still may not change the clinical outcome. I then said, “So if a patient’s clinical outcome will not be impacted, then you don’t want your patient’s pain managed? Nor call lights answered?” The physician answered that of course he would want these steps to be taken.

That’s when it hit me. While I can connect the dots and also show more research that indicates a connection between patient satisfaction and clinical outcomes, the evidence really isn’t the point. There are times when even if actions do not impact the clinical outcome, certain behaviors and actions still need to be done.

Hospice caregivers do great work. Do their efforts change the clinical outcome? My first grandchild was stillborn. While the care and support given to my son and daughter-in-law did not change the clinical outcome, were they worthwhile? Yes, without a doubt.

Why do some people fight making some basic changes? I can’t take inventory for others, but based on years of experience, I do have some observations of my own.

For some people, it has to do with not being comfortable. If I am asked to do something that I am not comfortable doing and can come up with a reason not to do it, I have found a way to stay in my comfort zone. For others, I believe it is the fear of failure. They would rather not try at all than try and fail. I believe this is one reason best practices are hard to transfer in healthcare.

Some people may feel they are the voice for others. Have you ever noticed when someone is pushing back, he or she may often say, “Everyone,” “Most people,” or “Others,” rather than coming out and saying, “Here is how I feel.” Still others may feel they need more data before they can make a change.

It’s that last group of people, the data-seekers, who bring me back to the point. How much evidence is enough to make a change worthwhile?

I have come to this conclusion: There are times in life when we do the behavior even though there is not overwhelming research data to support it. We do it because it is the right thing to do. I can think of no reason more powerful than that one.

16 Responses to “How Much Evidence Is Enough?”

It seems that the physicians you spoke to were simply looking at the physical well-being of the patient while not seeing the importance of the emotional and spiritual well being of the patient. One of our core values is treating the patient wholistically. Patient satisfaction encompases the whole patient and her/his well being.

In our last Directors meeting, our CEO read a letter from family member of a patient who had died in an ambulance on the way one of our ER’s. The letter was written to say thank you for the care and compassion that given to his family by the ER staff. The letter stated that his family member was put into a hospital gown, given an arm band, cleaned up, and treated as any other patient so that his family could have their time to say goodbye. This certainly could not and did not change the clinical outcome for this patient. But it was definitely the right thing to do and this family will never forget the kindness that was shown to them by this ER staff.

I’m not sure that there is any action, whether large or small, that does not impact clinical care. If a patient is treated with care and respect, it can affect their mood and their self-esteem. These, in turn, can affect everything from pain management to digestion. A patient survey could give a patient a sense of empowerment and some level of control over their disease process and plan of care. This could affect compliancy and definitely affect clinical outcomes.

Thank you Quint…My partner and I struggle with this all of the time….we show why being kind is so valuable and yet they refuse to do it….….they are clinically excellent but think of this as only fluff….it is funny when I looked at our PS Scores the reasons we didn’t get high marks wasn’t due to clinical excellence…..it was due to the patient not feeling respected or treated with dignity, they didn’t feel anyone really cared about their personal being and no one really communicated with them………This fluff that I call just good manners is all our hospital needs and yet when you go in a train on manners they roll their eyes and go back to yelling and ignoring the patients…. It seems so funny that something so easy and something most of us learned as we were growing up could be so hard for us to do as adults…..we will keep working on rounding the sharp corners.

Quint, thank you for this forum and I respect the great work you do and your team provides.
Patient Survey’s are important and can be used to monitor the patients perception of the care they received on the treatment of their symptoms. It can also be valuable to hospital executives to monitor the care, compassion and respect their patients are receiving from their staff. Matching this to clinical outcomes (diagnosing and fixing the root causes of those symptoms)in my opinion, is the focus of physician groups across the country and it is not easy. “Change Management”, bridging communication gaps and fixing internal processes that are broken and transitioning to a culture around continuous process and performance improvement that focuses on outcomes, is the critical first step. Basically, how well your symptoms are being cared for and monitored is important and needs to be done regardless of outcome, but falls short in addressing the root causes of those symptons. It doesn’t reflect how well hospital departments, nurses, doctors, prescribers and administrations are working together and communicating effeciently to understand each other’s needs, the patient’s needs and the proper diagnosis of the “Root Causes” of those symptons. Addressing the root causes to the symptoms impact patient outcomes more so than the patient satisfaction surveys. In my opinion, matching the two will happen when the patients symptoms are cared for and the needs of the doctors and care providers are met. This culture transformation will start to happen when the bridge between clinical outcomes and financial objectives are brought together. I also want to thank all the doctors, nurses and healthcare practicioners who work very hard everyday to save lives….

That very physician who questioned you has probably not gone on “mission” trips to underserved areas, as some of our physicians do each year. These physicians, no doubt, make a difference in people’s lives. However, there is also little doubt that the treatment of the poor in underserved countries will probably not change their plight/outcome of their lives.

So the evidence is there…..the evidence says it makes no difference in the long run, so perhaps it should not be done! Try to hold back the desire of physicians and nurses to share of themselves for the betterment of others.

Well said, Quint. Doing the right thing is always the right thing to do, regardless. (The value of please and thank you is frequently underrated but is an essential.)

I have worked facilitated and implemented Lean practices for 10+ years and have found that level of discomfort associated with change is typically very high. The running answer is that ‘We’ve never (or always) done it that way. It has always worked. Why should we change.’ Change comes hard to many, if not most, people.

Does respect affect clinical outcomes? I would suggest that how a patient perceives his/her care may have direct or indirect relationship to some patients ultimate outcome. I may not be able to prove that statistically but my personal observations say it is the right thing to do.

Over the years I have been asked many times “how have you stayed in oncology for so many 15+ years?”. My answer is always because I love the patients and families. We try everyday to cure our patient’s and unfortunately we do not always succeed, but they know that we are trying to do our best to help them in this horrible time. The quality of clincal care and quality of emotional care is such an important factor for all patients and families. Communication is such an important key and both the medical staff and patient should have an open communication. In today’s world we have constant change around us and we need to be able to communicate effectively and openly to facilitate change. Patient and family satisfaction scores are important as well as the clinical components.

Hello Mr. Studer,
Thank you for a blog that was so worth reading! As I began to read, the first thoughts that came to mind were that we do what we do because it is the “right thing to do”. However, I also realized that what I consider as the right thing to do, others do not. So the greater question then becomes, how do I motivate my team members to be focused on customer satisfaction and to model the behaviors that often do not come naturally. I think the answer, while seemingly simple, is more difficult than we think. I simply model the behavior myself and expect the same from the staff. Easy, right? No, sometimes exceedingly difficult because egos, the need to always be right, subjective reasoning without considering another point of view and I am sure many other reasons as to why we all struggle with the same problems will always be big rocks on the road to doing the right thing for the patient. We need to learn how to break up the rocks and clear the road! That is certainly my greatest personal challenge.

I guess what I am saying is that in this service driven industry, one must have a true service heart. As Stephanie Baker points out, sometimes we only have one chance. We need to make it count. That small gesture of offering a blanket or a pillow, changing a position, rewarming a meal, offering a listening ear,giving an update, showing a sense of urgency, making a phone call make a difference!

Thank you for an excellent read! I so appreciate everything you and your staff do to help me keep my spark well lit. You have rekindled it more times than I can remember.

Mr. Studer, Thank you for your words and insight. I am a hospice nurse that certainly believes strongly in evidence based practice. I have found in life many issues and decisions can remain black and white, yet as human beings spend much too much time creating gray areas. I echo what John B. stated, doing the right thing is always the right thing to do…

While you are completely right, I’d like to offer another perspective, that we can’t separate “clinical quality” from patient satisfaction. Patient satisfaction is an integral dimension of the the quality of medical care. It is wrong to think that making the right diagnosis and prescribing the right treatment means great clinical care is given even if patients are unhappy.

Sure, making the right diagnosis and prescribing the right treatment are essential elements of great medical care, but by themselves they are not sufficient. Patients must feel cared for, too.

Just the other day while sitting at a high school game a former kindergarten student told me that the best year of her life was her kindergarten year. I took it as simple conversation until she stopped me and said “no really! You made me feel like I could do anything if I tried and your classroom made me feel like I belonged. I don’t think I learned very much since then. I’ll never forget how good you made me feel.” This student is now a freshman at WVU and going into the medical field. If you think the small acts of kindness aren’t important think again. Do you think those memories will affect her attitude and spill over into health care in the future? Data is important but sometimes the greatest impact cannot be measured and translated into numbers. Keep doing the little things because SOMEONE is measuring them! Doesn’t matter what field you’re in.